African care for congenital central nervous system disorders: Falling far short of global management standards?
Authors: Andrew A. Wireko, Pearl Ohenewaa Tenkorang, Anastasia Fosuah Debrah, Teni Akin-Olugbemi, Rohan Yarlagadda, Aashna Mehta, Jyi Cheng Ng, Toufik Abdul-Rahman, Marios Papadakis
Journal: International Journal of Surgery (2023)

Dear Editor, Congenital central nervous system (CNS) disorders are anatomical or functional abnormalities of the CNS that arise during pregnancy and are present at birth1. There is a wide range of congenital CNS disorders but the most common types are the neural tube defects. Anencephaly, encephalocele, and spina bifida are the most common types of neural tube defects1. Birth defects continue to be a major global concern due to their high mortality rate, accounting for more than 20% of all infant deaths1. Reports on the prevalence and risk factors of congenital defects, particularly CNS disorders, are insufficient in Africa due to a lack of data from the countries' National Birth Defect Registries2. There are no definite causes associated with 50% of congenital disorders, but the main causes have been identified as chromosomal anomalies, teratogens, intrauterine abnormalities, and single gene disorders3. Aside from the major causes of congenital CNS disorders, consumption of naturopathic medicine, which is primarily made up of herbs from unknown sources, has been identified as one of the major causes in the context of Africa3. These herbal medicines contain teratogenic substances that may harm the fetus. Other factors such as viral or bacterial infections, folic acid deficiencies, periconceptional exposure to high doses of irradiation, and chemicals also play a significant role in the development of congenital anomalies in Africa4. Although Africa lags in the management of congenital CNS disorders, there has been significant progress in recent years. Certain African countries, including South Africa, Ghana, Nigeria, and Cameroon, have implemented a mandatory folic acid fortification policy, with the knowledge that folic acid supplementation during pregnancy can help prevent a variety of congenital malformations5. Despite this, a large proportion of the African population remains without these policies, especially those based in Eastern Africa, and thus do not receive this standard of care3. The substandard management of congenital CNS disorders in Africa has several contributing factors. First, the scarcity in specialists trained in the management of these conditions causes patients to resort to treatment by nonspecialists. Many patients do not have access to routine care; this leads to an inconsistent level of care6. Second, a lack of a central vaccine administration programs for infections like Haemophilus influenzae type B and conjugate pneumococcal results in the continued prevalence of diseases like meningitis which has largely disappeared in high-income countries. Meningitis is known to be responsible for causing congenital CNS disorders, and its prevalence along with other preventable infections leads to a heightened risk for CNS disorders6. Poverty and illiteracy are major contributors to the burden of managing congenital CNS disorders in Africa2. It is well known that the majority of the African population is still impoverished; for example, 57% of those in sub-Saharan Africa remain poor2. Due to the lack of reliable diagnostic centers and equipment, people often disregard antenatal services, and folic acid supplements are rarely available. Precise and definitive diagnosis is at the heart of the management of congenital CNS disorders3. Quality diagnosis necessitates the reliance on highly skilled medical personnel such as neurologists, neurosurgeons, radiologists, and others, as well as cutting-edge neuroimaging technology3,7. Only a few countries, such as Egypt and South Africa, have centers that provide prenatal screening, diagnosis, treatment, and follow-up services, and even those that do exist either have outdated equipment or are not accessible to the economically disadvantaged3. The dearth of well-founded information on congenital CNS cases in Africa indicates the huge research gaps in Africa to critically assess the issue3. While the incidence of congenital anomalies is decreasing in developed countries, Africa continues to be burdened with this problem. It may be seen that the preventative measures adopted by other developing and developed countries that have led to such positive outcomes are unfortunately absent or insufficient in African nations. The burden of these diseases remains high in African nations, and this emphasizes the need to determine strategies to alleviate this burden on African countries. One such strategy is that governments should be encouraged to develop healthcare policies that emphasize the importance of prenatal care so that pregnant women get access to regular care and monitoring to improve fetal development. This could be achieved by implementing an educational framework to raise awareness in the population. To ensure quality management, African countries can also benefit from making healthcare facilities and well-trained physicians more accessible to bridge the treatment gaps. The shortage of healthcare professionals, particularly neurologists, neurosurgeons, and radiologists for complex CNS cases should be improved by establishing more training centers. More medical schools should be established in Africa to train more medical personnel to alleviate the burden of physician shortages in African countries. Also, the working conditions of healthcare workers in Africa need to be improved to avoid the emigration of professionals in the health sector to high-income nations. Furthermore, African governments should ensure that diagnostic centers are not limited to urban areas; thus, diagnostic centers should be fairly distributed across the continent, particularly in rural areas. The majority of Africa's population are found in rural areas so more emphasis should be placed there. The cost of accessing diagnostic services for fetal screening should be accessible and affordable to all pregnant women, regardless of socioeconomic status. Africans can address the problem of illiteracy and lack of knowledge about proper antenatal care by providing consistent public education and raising public awareness. It will be important that the population is educated about the critical importance of folic acid and a well-balanced diet during pregnancy. They must also be well-informed about the teratogenic effects of herbal medicine, alcohol, and certain drugs on fetuses. This can be achieved either via government-backed programs, distribution of pamphlets, or through discussions with their local physicians. Finally, effective National Birth Registries should be set up for all African nations to efficiently monitor all congenital cases. Policies should be enacted to ensure that all births are accounted for and to avoid the data gaps that have been noted traditionally. The recorded data from these registries could serve as a good foundation of quality research activities on the continent to effectively assess congenital anomalies and improve outcomes. Ethical approval and consent to participate Not applicable. Sources of funding None. Authors' contribution A.A.W. contributed to conceptualization ideas. All authors were involved in data curation, writing of the initial draft, review and editing, and approved the final manuscript. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Andrew Awuah Wireko.